MSF Portal

Compulsory Fields

Applicant Information

I do not want to receive mailers from and/or be contacted by SG Enable for related services and schemes in the future.

Please print the Filled Application and Household Information Section or fill Section 1 of the ATF Application Form and upload with signature (Optional)

Applicant & Household Information

Section Completed By

- Compulsory Fields

Disability Information

e.g. Limb Amputation, Muscular Dystrophy, Optic Atrophy

Device Information

Device Category	Device Type	Device Description	Device Outcome	Actions

e.g. Elaborate how device will benefit the applicant, justification of chosen AT, etc.

Please state why in your view a therapist/doctor report was not necessary. e.g. Applicant is recommended a repair/replacement/ upgrade of device. Please provide any medical documents stating permanence and type of disability where available.

Assessor Information

Supporting Documentation

Assessor's Report

I confirm that the assessment done for the above applicant is true and correct to my best knowledge. I obtained consent from applicant for the assistive technology device(s) that are recommended to him. I am aware that the assessment for this application will serve as reference. SG Enable reserves the right to make the final decision on the application outcome and reject any application if the information is found to be inaccurate, or if any relevant information has been withheld by applicant.

Section Completed By

- Compulsory Fields

Recommendation - Application Admin's Report

Please assist applicant and household to complete Means-Test Declaration Form before proceeding with application.

Please indicate % requested based on your assessment of the applicant's financial ability to co-pay.

State the reasons if funding percentage requested is higher than ATF qualified subsidy and if alternative co-payment modes such as installments or external funding can be explored.

Note: Double funding for the same device(s) is not allowed

For applicant 60 years old and above

Has subsidy been sought from other funds such as AIC SMF or HDB Ease for this device(s)?

Check the option(s) that apply

Please specify

Additional Information

Other Supporting Documents (If Necessary)

Section Completed By

Application Type:: Financial Schemes

Date of Submission:

Status:

Submitted by:

Date of Approval:

Organisation Name:

Service Introduction

Applicant & Household Information

Applicant Information

I do not want to receive mailers from and/or be contacted by SG Enable for related services and schemes in the future.

Applicant & Household Information

Section Completed By

Recommendation - Assessor's Report

Disability Information

Device Information

Device Category	Device Type	Device Description	Device Outcome

Please Elaborate How Device will Benefit Applicant

Assessor Information

Supporting Documentation

Assessor's Report

I confirm that the assessment done for the above applicant is true and correct to my best knowledge. I obtained consent from applicant for the assistive technology device(s) that are recommended to him. I am aware that the assessment for this application will serve as reference. SG Enable reserves the right to make the final decision on the application outcome and reject any application if the information is found to be inaccurate, or if any relevant information has been withheld by applicant.

Section Completed By

Recommendation - Cost & Quotation

Device Information

Device Description	Net Cost (S$) (Including GST where Applicable)	Vendor	Quotation Reference No.(If Available)

Vendor's Report

Section Completed By

Recommendation - Application Admin's Report

Application Admin's Report

State the reasons if funding percentage requested is higher than ATF qualified subsidy and if alternative co-payment modes such as installments or external funding can be explored.

For applicant 60 years old and above

: - ;

Additional Information

Other Supporting Documents (If Necessary)

Section Completed By

Subsidy Disbursement

Approved subisdy disbursed to the following

Cheque Mail Address

Section Completed By

Select an Endorser

Endorser

Section Completed By

Declaration

Being the person disclosing the information and making the application for the purposes as set out above or being duly authorised by such persons disclosing the information and making the application for the purposes as set out above, we agree to the above.